Assist with responding to incidents

BSBWHS403: Assessment 1

Semester 1, 2019

Maung Maung SOE,

SID: 802653743
17 March 2019
Maung Maung SOE BSBWHS406 Assignment 1

Task
Using your workplace or one that you are familiar with, provide answers to each of the
following tasks.

1. Provided a brief description of your chosen workplace and the activities

that are carried out in the area where the incident has occurred.

 Tile manufacturing and distributing company

 Administration office, production area, warehouse, waste damping area
 Administration staffs, supervisor in warehouse, Foreman, leading hands and designers

Explain what policies, procedures, processes and system are in place to

respond to an incident and to carry out an incident investigation.

KHardy Incident Response Procedure

1. WHS Policy

The aim of this ‘incident response procedure’ is to ensure that all incident in, or have the
potential to cause injury or damage, are reported and investigated and actions are taken to
prevent a recurrence.
It applies to all workers, or other persons, at sites operated by ‘KHardy Tile Warehouse’.
The company is committed to the establishment, monitoring and review of health and safety
objectives and targets to ensure continuous improvement aims at the elimination of work
related illness and injury.

2. Procedure

2.1 First Aid Treatment

Immediately following an incident that involves personal injury first aid treatment may be
required to comply with WHS Regulation 2017 Clause 42. Penalty will be A$ 30,000 if
failed to do so.
Assistant should sought initially from the designated first aid officer, and finally from
professional medical personnel if required.

2.2 Serious Injury or Dangerous Incident

In the event of a serious injury or dangerous incident the following steps should be
considered:

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Maung Maung SOE BSBWHS406 Assignment 1

2.2.1 Seek Emergency Assistant if Required

Determine if emergency services (Police, Fire, Ambulance) are required, and if so contact
emergency services (Ph:000).

2.2.2 Take Control of and Secure the Incident Site

The manager or supervisor is to secure the incident site to preserve it for later examination if
required.
The site must be controlled in accordance with the Section 39 of the WHS Act-2011, so that it
isn’t disturbed until it can be inspected by a WHS inspector.
Securing the site should not hinder or prevent assisting an injured person, or making the site
safe to prevent further incidents.
This site may be alerted with permission from an inspector or the regulator.

2.2.3 Internal Notifications

 First Person on the scene: If required, should contact the designated first air officer,
emergency services, manager or supervisor and, if applicable, any contractors on site.
 Manager/Supervisor: Should notified WHS personnel as soon as practicable, and ensure
first aid or emergency services have been contracted if required.
 WHS Personnel: Should communicate to workers to keep them aware of developments.

2.2.4 External Notification

 Contact ‘NT WorkSafe’ to notify of a reportable incident.
 Contact ‘NT EPA’ if required to notify of an environmental incident
 Contact ‘Power & Water’ if required to notify of a serious electrical incident.

2.3 Investigation Report

An investigation report must be completed for all incidents resulting in fatality/serious

injuries or illness.
It is also required if a risk assessment indicates a potential risk of ‘High’ or ‘Very High’ or
where the underlying causes of the incident are unknown.
The investigation team is to be nominated by the ‘WHS Committee’ and may involve ‘WHS
Representatives’, as per section 68 of the WHS Act-2011.
All related reports should be saved as attachments to the original incident notification.
2.4 Incident Investigation

The purpose of the Incident Investigation is not to attribute blame, but to:
 Identify contributing factors to the incident
 Assess the risk
 Determine potential control measures to prevent recurrence.

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Maung Maung SOE BSBWHS406 Assignment 1

Once the incident causes have been identified a risk assessment should be conducted. Risk
control measures should be ranked in order of priority using the hierarchy of control of
eliminate, substitute, engineering, administrative and Personal Protective Equipment.
Once control measures are implemented they are to be check to ensure risks are eliminated or
minimised, reviewed to check effectiveness, and monitored to ensure they remain effective.
2.5 Worker Compensation and Rehabilitation

If an employee suffers an injury or illness which arises out of, or in the course of their duties,
they may be entitled to Workers Compensation.
KHardy will take all reasonable steps to achieve physical and psychological rehabilitation of
injured employees.
3. Responsibilities

The manager is responsible for ensuring:

 This procedure is implemented effectively including the control/preservation of notifiable
incident sites, notification of incidents, and the completion of incident and investigation
reports.
 The regular (NT WorkSafe) is notified immediately after becoming aware that a notifiable
incident has occurred, in accordance with Section 35 of the WHS Act 2011.
 A record of each notifiable incident is kept for at least for at least 5 years from the day that
notice was given to the regulator.
Workers and other persons are responsible for ensuring that any incident they are involved in,
or witness, is reported in accordance with this procedure.
4. Supporting Documentation
 WHS Act – 2011
 WHS Regulations – 2017
 Preparing an Incident Response Plan – Qld Government – Business & Industry Portal
2016
 Charles Darwin University – First Person on Scene Procedures - 2013
 Charles Darwin University – Emergency Management Plan 2008
 Charles Darwin University – Incident planning committee Terms of Reference - 2014
 Charles Darwin University – Critical Incident Response Group procedure - 2014
 AS3745-2010 Planning for Emergencies in Facilities.
 Section 44 of the workplace injury management and workers compensation Act
19998
 Register of injuries section 63 of the workplace injury management and workers
compensation Act 19998
 Clause 32 of the workers compensation Regulation 2003
 Section 35-39 of WHS Act 2011
 Clauses 536-549 and 649 of WHS Regulations 2017

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Maung Maung SOE BSBWHS406 Assignment 1

2. Choose an incident investigation form of your choice and attach a blank

copy of this form to the end of your assessment – Appendix “A”

Attached with Appendix “A”

3. Carry out a SWOT analysis of your chosen incident investigation form
and briefly explain the strengths, weaknesses, opportunities for
improvement and potential threats associated with this investigation
form.

SWOT Analysis
Strengths Weaknesses
 Excellent covering of injured details,  Poor record keeping in general. This
treatment and corrective action to be could be difficult to trace back in
taken. future if there is no document
 Excellent in injury details parts with a number.
pictures of front and back of person.  Poor format in incident description
 Clearing stated that who would be and corrective action to be taken and
filling-in this report accordingly and implementation. It is too broad to
where to go after this. write.
 Providing very good guideline for  No specific record of witnesses of
recommended corrective action other person involved.
 No contribution factors that could
lead to incident
 No immediate action
Opportunities Threats
 Incident description can be broken  No notification process for
down into a few tops such as legalisation
 Time, place, and what happen  No risk assessment investigation
 Is this task belonging to his duty?
 Who are involved including witnesses
 Any injuries and damages of
equipment and building
 Photo taken
 Immediate action
 Add a session for contribution factors
such as weather, environment,
equipment, materials, work systems
and people so that the report will be
more clear
 Corrective action plan should be table
form with action to be taken, by
whom, by when and completions date
so that everyone knows who to
approach for completion of this
action.

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Maung Maung SOE BSBWHS406 Assignment 1

4. Choose an incident that occurred in your workplace or a workplace that

you are familiar with. The incident must involve a worker at the
workplace who was injured or became ill and required first aid treatment.
Using the selected workplace incident, answer each of the following
tasks:

a. Provide a brief explanation of the incident. Your explanation must

address each of the following dot points:
 what actually occurred (i.e. incident event)
At approximately 1:20 p.m. on January 2013, Employer #1 used a plasma cutting torch to
remove the top from a 44 gallon drum. The employee was just beginning to cut the drum
when the bottom exploded, engulfing him in flames and launching the drum. Worker #1
suffered burns to his legs, broken right forearm and lacerations.

 lead-up events and circumstances prior to the incident

 On the 15th October 2012, the supervisor at Khardy Tile Warehouse manufacture plant
purchased a drum of industrial degreaser to be delivered to KHrady so that the shop floor
of the manufacturing plant could be cleaned. Delivery of degreaser arrived on the 21st
October and the floor was cleaned by workers on the 24th October. Upon completion of
the task, the empty drum was relocated to the waste area at the rear of the compound two
days later, where it would sit waiting to be disposed of.
 Going to the waste storage area of the site compound, a worker moved the 44 gallon drum
which has previously contained a highly flammable degreaser off to one side.
 The worker then tool plasma cutting equipment to the waste site area with the intention to
cut the top off the 44 gallon drum, so that the drum could be used to store surplus clay
from the manufacturing of terracotta tiles.
 The drum has previously contained a highly flammable degreaser, which has a flash point
of 215 degrees C. The drum had not been thoroughly cleaned prior to the cutting and the
bung has not been removed.

 the events/actions taken immediately following the incident

(first aid, area made safe etc).
 Stop what I am doing and act accordingly
 Ensure the victim is in no immediate danger and make him comfortable.
 Stop excessive bleeding; this treatment must be given by designated first aid officer.
 Signals and signage.

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Maung Maung SOE BSBWHS406 Assignment 1

 was this a “Notifiable incident” under current health and safety

legislation in your State or Territory? What Section of the
WHS/OHS Act did you need to look at to answer this question?
It is a notifiable incident as this is fall into a serious injury or illness of a person. According
to Sections 35-39 incident notification of WHS Act 2012, failed to do this will be fined up to
A$ 10,000.

 what assistance did you or other personnel provide to the

injured worker e.g. first aid?

 Co-workers rushed to the man’s aide and an ambulance was called taking the 31 year old
male worker to hospital to be treated for burns, broken arm and lacerations received from
the blast.
 Communicate with paramedic and providing assistant first aids needed according to their
instruction before their arrival.

b. Complete the incident investigation form that you have chosen in

question 1 and attach it at the end of your assessment – Appendix
“B”.

Attached with Appendix “B”

c. Explain how you assisted in the investigation process.

The purpose of the incident investigation is to do fact finding, not fault finding, so effort
should be put into determining the causal contributing factors and not assigning blame to
individuals.

 Gather the necessary people to conduct the investigation.

 Secure the area where the incident occurred and preserve the work area as it is.
 Identify and gather witnesses to the incident.
 Interview the injured worker as soon as possible.
 Interview all witnesses as soon as possible.
 Document the incident scene through photo’s or videos.
 Complete the investigation report, including determining the causal factors as well as
determining what corrective actions will prevent a recurrence.
 Ensure follow up on completion of corrective actions.
 Register of injuries in the log book.

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Maung Maung SOE BSBWHS406 Assignment 1

d. Using your explanation of the incident in “a)” and the completed

investigation form in “b)” analyse the incident, identify and list the
root causes that lead to this incident and explain the reasons for the
occurrence (e.g. poor supervision, no safe work method in place,
equipment failure due to lack of machine maintenance, etc.).
The incident was caused by a lack of WHS management, training and knowledge. A lack of
supervision allowed workers to continue beyond where WHS issues should have stopped
work and allowed the incident occur.
Time line
 October 15th 2012: Drum of degreaser ordered
 October 21st 2012: Drum of degreaser delivered
 October 24th 2012: Floor cleaned with degreaser and empty drum taken to waste area for
temporary storage.
 January 15th 2013: Worker attempted to cut the top from the drum, causing a subsequence
explosion resulting in him suffering burns, a broken arm, and lacerations.
Reasons for incident
 Empty drum was not cleaned immediately and delaying of the process of waste disposal.
 This drum, yet sealed drum, full of flammable vapour was left for nearly 3 months
without proper cleaning
 Signage of flammable on the drum might have been removed or invisible and no warning
near to the waste storage area.
 SDS may or may not available. If available, workers involved in this incident are not
aware of SDS information.
 Risk Assessment or Safe Work Procedure might not be done before doing this job.
 The injured worker was obviously not aware of the flammable hazard.
 The injured work must have been lack of communication for consultation, knowledge of
safe work procedure and/or training before handing this job.
Hazard:The flammable chemical hazard (Degreaser)
Cause of the incident
 A lack of training and/or communication/consultation
 A lack of a risk assessment development
 A lack of suitable procedures for dealing with the flammable hazard.
 Leaving a flammable hazard for an extended period with no attempt at cleaning or
reducing the risk
 No supervision during work
Recommendation
 Develop training program for handling unusual work including consultation processes
 Risk assessment must be carried and approved by supervisor or HSR before handing the
job
 Develop work safe procedure (SWP)
 Clean the drum as soon as possible before moving into waste area
 Closed supervision is required

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Maung Maung SOE BSBWHS406 Assignment 1

e. Provide details of the risk assessment process that was used during
the investigation.
The incident was caused by a lack of WHS management, training and knowledge. A lack of
supervision allowed workers to continue beyond where WHS issues should have stopped
work and allowed the Is this job a part of your duties?
 Did you do risk assessment before commencing this task? If NO, can you explain me
why you did not do it.
 Did you know about the hazard and risk of this job?
The following lists will be found out as an investigator to process.
 What is the hazard in here? “ Flammable Gas and Hot Work”
 What is the risk for this task? “Fire and explosion”
 What type of control is required for this task? “ remove gas as much as possible, PPE, Hot
work permit, seal the area, work under supervisor”
 Regulation, Code of Practice and Standards for this task.
o WHS Regulation 2017: Chapter 3 Division 5 Personal Protective Equipment
o Code of Practice _ How to manage work health and safety risks
o Standards AS 1674-1997 Safety in welding and allied processes – Fire
precautions.
 What is the minimum standard and procedures apply to this task?
o PPE, Hot Work Permit, Supervising
f. Develop an Action Plan that lists the corrective actions (risk control
measures) that you would implement to prevent the incident
recurring. This can be set out in a table format using the following
headings: Root Cause(s) / Risk Rank / Corrective actions required /
Person responsible / Due date

Root Risk Corrective Person(s) Due Date

Cause(s) Rank Action Responsible
High  Develop training Training 07 Feb
 No training
program officer + 2013
Safety Officer
 Carried out risk warehouse 01 Feb
 No risk
assessment for all supervisor 2013
assessment
tasks with
consultation
 Develop safe work Warehouse 05 Feb
 No SWP
procedure for each supervisor 2013
work
 Develop cleaning Warehouse 01 March
 No Cleaning
and waste disposal supervisor + 2013
procedure HSR
 Provide close Ware house 05 March
 No supervision
supervision supervisor 2013

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g. Explain how you will assist in ensuring that the corrective actions
are implemented in a reasonable timeframe.

Corrective Actions will be documented and monitored against an assigned timeline. One
person will be assigned to undertake this task and doing regular review of all corrective
actions. He/ She is required to report on the status to the investigation team leader and
relevant HSC/HSR on the regular basic.
Corrective Actions that have not been implemented within assigned time will be reported to
the manager to take further action.

5. Provide a reference list of sources of additional information and data

both internal and external that could be used to assist investigators in
future investigations eg.
 Codes of Practice
 First Aid in the work place
 Labelling of workplace hazardous chemicals
 How to manage work health and safety risks
 Hazardous Manual task
 Work health and Safety consultation, co-operation and co-ordination
 Relevant Clauses of the WHS Regulation 2017
 WHS Regulation 2017 Clause 573 Notification
 WHS Regulation 2017 Clause 669
 WHS Regulation 2017 Clause 42 Provision of first aid at work
 Clause 32 of the workers compensation Regulation 2003
 Clauses 536-549 and 649 of WHS Regulations 2017
 Return to Work Regulation
 Dangerous Goods Regulation
 Relevant Section of the WHS Act 2011
 WHS Act 2011 Sections 35-39
 WHS Act Part 2 Division 5 Offences and Penalties
 Section 44 of the workplace injury management and workers compensation
Act 19998
 Register of injuries section 63 of the workplace injury management and
workers compensation Act 1998
 Return to Work Act
 Dangerous Goods Act
 Work Health Administration Act
 Work Health Court Rules

 Relevant Australian Standards

 AS3745:2002: Emergency Control Organisation and Procedure

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Maung Maung SOE BSBWHS406 Assignment 1

 AS/NZS4801:2001 Occupational Health and Safety Management System

 AS2444:2001 Fire Extinguishers and Fire Blankets
 AS3745-2010 Planning for Emergencies in Facilities.

 Injury Register data, and

 Working safely in Australia information sheets
 Guide for Major Hazard Facilities – Emergency plans
 Understanding Safety Data Sheets for Hazardous Chemicals
 Hazardous Chemicals Register Fact Sheet

 Safety alerts produced by the Regulator

 NTWorkSafe Work health and safety – incident notification
 Others
 Notification and determination – Guide for major hazard facility
 ISO19703:2005 Generation and analysis of Toxic gases in fires
 HB 205: 2004 OHS Risk Management handbook
 Improvement notice or prohibition notice

Checklist
I have:
 Completed ALL questions in this assessment
 Referred to health and safety legislation operating in my State/Territory
 Included a bibliography and used Harvard referencing
 Included my name, student number, unit number, assessment number
 Reviewed and spell checked my document
 Saved a copy on my own computer.

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Bibliograph

Archer, R, Borthwick, K, Travers, M, Ruschena, L (2012) WHS: A management Guide

Cengage Learning, Melb.
CCH Australia, 2003, CCH Occupational Health and Safety and Environmental; Master
Guide CCH Australia Limited
CCH Australia, 6th Ed, 2004, Planning Occupational Health and Safety, CCH Australia
Limited.
Charles Darwin University “ Accident, Incident and Injury Report”
Dunn, C (2011) Planning Work Health and Safety, CCH, Sydney
Dunn, C, Chennell, S (2012) Master Work Health Safety & Environment Guide CCH, Sydney
MBC, 2006, Participant Guide: Manage OHS in the workplace, Pearson Education
Australia
NTWorkSafe Website, http://www.worksafe.nt.gov.au
Safe Work Australia Website, https://www.safeworkaustralia.gov.au
Toohey, J.,Borthwick, K., & Archer, R. 2005, OH&S in Australia a Management Guide
Thomson
University of Tasmania “ Work health and Safety Investigation Form”
Work health and Safety Act 2011, Website: https://www.legislation.nsw.gov.au
Work Health and Safety Regulation 2017, Website, https://www.legislation.nsw.gov.au

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Appendix “C”

KHardy Tile Warehuose

Incident Report Summary- Drum explosion

The following information is extracted from OHS Alert www.ohsalert.com.au Posted 11 feburuary
2016 1:46 pm.

A new WHS system, due diligence training promised in KHardy Tile Warehouse as a result
of the following incident.

KHardy has committed more than $200,000 to overhauling its safety management system and
providing WHS training to staff, after being accused of WHS breaches.

NT WorkSafe alleged KHardy Tile Warehouse Ltd Pty breached the WHS Act – before agreeing to an
enforceable undertaking – after a KHard worker was injured by a drum explosion in January 2013.

Incident Summary

On the 15th October 2012, the supervisor at Khardy Tile Warehouse manufacture plant purchased a
drum of industrial degreaser to be delivered to KHrady so that the shop floor of the manufacturing
plant could be cleaned. Delivery of degreaser arrived on the 21st October and the floor was cleaned
by workers on the 24th October. Upon completion of the task, the empty drum was relocated to the
waste area at the rear of the compound two days later, where it would sit waiting to be disposed of.

Going to the waste storage area of the site compound, a worker moved the 44 gallon drum which
has previously contained a highly flammable degreaser off to one side.

The worker then took plasma cutting equipment to the waste site area with the intention to cut the
top off the 44 gallon drum, so that the drum could be used to store surplus clay from the
manufacturing of terracotta tiles.

At approximately 1:20 p.m. on January 2013, worker #1 used a plasma cutting torch to remove the
top from a 44 gallon drum. The employee was just beginning to cut the drum when the bottom
exploded, engulfing him in flames and launching the drum. Employee #1 suffered burns to his legs,
broken right forearm and lacerations.

Co-workers rushed to the man’s aide and an ambulance was called taking the 31 year old male
worker to hospital to be treated for burns, broken arm and lacerations received from the blast.

The drum has previously contained a highly flammable degreaser, which has a flash point of 215
degrees C. The drum had not been thoroughly cleaned prior to the cutting and the bungs has not
been removed.

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Outcomes

The following the incident, the company was issued an improvement notice and responded by
spending $10,050 on: conducting safety and toolbox meeting to discuss a ban on cutting drums and
enclosed vessels, as well as fire safety; developing job safety analysis documents on “performing
unfamiliar tasks” and conducting onsite first-aid courses with St John Ambulance for all supervisors
and Staff. Further to this, workshop foremen, leading hands, designers and administration staffs are
to attend a managerial training program.

As a part of the undertaking, the employer committed to establishing a new accredited work health
and safety management system, and providing systematic and comprehensive WHS training for all
staff.

It developed the system by holding round table meeting with staff from all levels, and drawing “on
the expertise of relevant areas of the business to develop sustainable safety initiative which are
designed to have the greatest possible impact on WHS”, the undertaking document says.

The management system will address safety across the whole organisation, but focus on
“entrenching the safety culture within the KHardy’s manufacturing workplace”.

Khardy will provide training sessions by internal and external providers on number of topics,
including: maintaining up-to-date safety knowledge; understanding the nature of the operation’s
hazards; providing resources; processes for receiving and considering information on hazards and
incidents; ensuring compliance with WHS obligations; and verification of the WHSMS.

The company has also committed to ensuring all staffs attend additional WHS training specific to
their role, and has put workshop managers, the WHS administrative coordinator, workshop leading
hands and administrative staffs through a health and safety representative course.

In the next step of the processes, KHardy’s general manager will undertake a Certificate IV in Work
Health and Safety, and all new current staff will be required to compete WHS system training on
topics including how to handle hazards and incidents, implementing JSAs, and complying with WHS
obiligations.

KHardy has also committed to initiatives that will benefit the industry by sharing the “lessons it has
learnt through this incident”.

It has commissioned a creative agency to produce a 30-second television commercial to “remind the
industry of the risks of cutting drums”, and has agreed to share this as a video safety alert on the
issue.

The video will be posted on the Regulator’s website. It will also be placed in the Manufacturing Skills
Austalia monthly newsletter, and presented by KHardy to local tertiary education institutions, to be
used as a part of the “Applied Safe Welding Practices”.

The total estimated value of the undertaking is $ 207, 250.

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